D Mutter (France), J Marescaux (France), L Soler (France)

September 2008

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This video presents the case of a female patient with an ethylic cirrhosis, diagnosed with a hepatocellular carcinoma located in segment IVa of the liver. The laparoscopic approach helps preserve liver function in patients with precarious liver conditions.

Clinical case presentationWe report the case of a 66-year-old woman presenting with a hepatocellular carcinoma developed on cirrhosis due to alcohol intake. The tumor is located in the segment 4 of the liver. The patient refuses to be transplanted for personal reasons. We decided to perform a laparoscopic resection. Preoperative localization was done with a CT-scan and with an MRI. A 3D reconstruction was performed to identify exactly the position of the lesion, simulate the resection and consider its position with regards to the vascularization of the liver. A one centimetre margin was considered for this resection. The simulation allows us to see that there were no major vessels included in the resection area.

01'19''

Liver exposureThe resection started with the exposure of the liver. Because of the patient’s pathology, we decided to preserve the integrity of the parietal wall by performing a laparoscopy, but also to preserve the round ligament, we decided to cut only the suspensory ligament of the liver without section of the round ligament in order to preserve the neo-vascularization.

01'48''

Intraoperative ultrasoundAs usual after exposure of the liver, the surgical procedure started with an ultrasonography. This exam allowed to confirm the tumor, its size, its location with regards to the vessels and also to confirm the lack of other lesions in the liver.

02'13''

Superficial tagging of the tumor and dissectionThe resection started afterwards without any Pringle’s manoeuvre; this was done in order to avoid any lesion of the remaining liver. We draw on the liver using electrocautery a one centimetre margin that we wanted to respect in this resection. As we can see, this required to resect a little part of segment 3 partially. The whole dissection was performed with three instruments, one held by the left hand of the surgeon, which was the bipolar cautery. The right hand of surgeon could manage an ultrasonic dissector and an AutoSonic device. The assistant was ready with a suction device in case of sudden bleeding. The whole procedure was performed with 4 trocars. The ultrasonic dissector is a very interesting tool for the dissection of the parenchyma. Nevertheless, the depth of the hemostasis that is performed with this device is not enough to control all types of bleeding. On the periphery of the resection, cauterization was always completed with bipolar cautery. The dissection was performed stepwise from the right side to the left side and from the left side to the right side regarding the little bleeding areas. If there is small bleeding, it is first controlled with bipolar cautery as you can see here, and then this region was compressed and the dissection was continued in another place anteriorly, laterally or posteriorly. Regarding this progressive dissection, first the resection margin of one centimetre was preserved. There was no significant bleeding despite the lack of major vascular control in this patient. The resection area was always controlled using a tape measure in order to be sure to respect the one centimetre margin of resection from the tumor. This means that a depth of 2.5cm was required to have a safe resection of this 15mm tumor. The suction device was also used as a retractor when necessary. The suction device allowed us to have a very clear operative field during the use of monopolar, bipolar cautery or during the use of the Harmonic dissector. Mobilization of the specimen can also be done using a small peanut, which is a very safe and very smooth atraumatic device that allows to mobilize the tumor without any disruption of the hepatic tissue. Here again, we can see that the suction device can also be used by the left hand of the surgeon who then places the instrument in his right hand. Dissection is then progressively completed and as planned, no major vessel is injured during this dissection. The specimen is freed, the resection area is controlled and if there are some bleeding points, further bipolar cautery is used.

06'54''

Specimen extractionThe specimen is placed into a bag, and extracted for macroscopic control of the resection margins.

07'05''

Specimen macroscopic margin confirmationThe specimen confirmed the 15mm tumor and the 1cm margin all over the resection area.

07'10''

Hemostatic control of resection areaThe resection area is once again controlled and for safety reasons, the Tacoseal system is placed all around the resection area in order to cover it completely. The objective is really to avoid any postoperative bleeding in the cirrhotic patient presenting vascularization and hemostatic traumas. As we can see, to complete the hemostasis and the covering of this area, 2 Tacoseal fleeces are required. These are introduced dry in the abdomen, and are then irrigated and compressed on the resection area.

08'08''

Drains placementFinally, the surgical procedure is completed by the placement of 2 aspiration drains that are kept for 2 days in case of biliary leak.

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